Can be HBeAg positive or negative, with generally higher HBV DNA levels in HBeAg-positive patients
ALT can be normal or elevated
Liver boipsy shows chronic hepatitis and variable necroinflammation or fibrosis
Immune-active
HBsAg present ≥6 months and HBeAg either positive or negative
Intermittently or persistently elevated ALT and AST
Indications for treatment
ALT ≥2x ULN or evidence of significant histologic disease, AND
Elevated HBV DNA
> 2000 IU/mL if HBeAg negative
> 20,000 IU/mL if HBeAg positive
Immune-tolerant
HBsAg present for ≥6 months and HBeAg positive
HBV DNA typically over 1 million
Normal or minimally-elevated ALT and AST
That is, high viral load but normal ALT
Indications for treatment
Adults >40 years, AND
ALT rises above 2x ULN (i.e. becomes immune-active), OR
Liver biopsy showing significant necroinflammation or fibrosis
Surveillance
Monitor at 3 to 6 month intervals, more frequently as ALT levels rise, consider treatment if >2x ULN/
Treatment Regimens
One of pegylated-interferon (48 weeks), tenofovir (until 12 months post-HBeAg conversion), or entecavir (until 12 months post-HBeAg conversion)
Peg-IFN contraindicated in autoimmune disorders, uncontrolled psychiatric disease, cyptopenia, severe cardiac disease, uncontrolled seizures, and decompensated cirrhosis
Peg-IFN preferred in lamivudine resistance
Tenofovir is safe in pregnancy
Duration depends on what stage is being treated
HBeAg positive and HBV DNA >20,000 and ALT >2 ULN
Peg-IFN for 48 weeks
Tenofovir or entecavir for at least 12 months after HBeAg seroconversion (Ag to Ab)
HBeAg negative and HBV DNA > 2000 and ALT >2x ULN (or biopsy shows necroinflammation or fibrosis, or non-invasive testing shows fibrosis)
Peg-IGN for 1 year
Tenofovir or entecavir for many years, possibly indefinitely
Continue HCC surveillance regardless of treatment
Inactive chronic hepatitis B
Defined by HBeAg-negative, anti-HBeAb-positive, normal ALT, and HBV DNA <2000 IU/mL
Monitor ALT q3mo for 1 year, then q6-12mo
If ALT rises, check HBV-DNA and HBsAg for activity
HCC screening
Screen if HBsAg-positive with cirrhosis, or HBsAg-positive at higher risk (Asian men >40yrs, black men >40yrs, Asian women >50yrs, family history, HDV coinfection)
First-line is ultrasound every 6 months
Second-line is AFP levels every 6 months
Prophylaxis in Immunosuppression
Concern especially with chronic steroids and rituximab
Can have the following effects
Asymptomatic HBV DNA and ALT
Hepatic failure
Death
If ≥7.5mg/d should be screened
HBsAg +/- HBcAb if they're adding a second agent (rituximab, TNF-alpha inhibitors, or other)
Refer to Hepatology or Infectious Diseases
Prophylaxis with lamivudine until 6 months after chemotherapy
^Mustafa Sunbul. Hepatitis B virus genotypes: Global distribution and clinical importance. World Journal of Gastroenterology. 2014;20(18):5427. doi:10.3748/wjg.v20.i18.5427.
